Rate of caesarean section births alarms experts

While there is overuse of the surgery in some counties, many deserving cases in other counties lack access to the procedure

Ms Rachel Mwende has no regrets about choosing to give birth to her third child by caesarean section.

She opted for elective surgery over natural childbirth just three weeks before her due date because she was suffering from chronic fatigue, something she had not experienced in her two previous pregnancies. She also wanted to undergo tubal ligation immediately after delivery as she did not want more children

“My doctor told me that it was the only way I could have my tubes tied at the same time. If I opted for a natural birth, I would have to wait for six weeks before undergoing the procedure,” she says. “It would have been inconvenient to return later for the surgery.”

Other common reasons include fear of pain, fear of pelvic damage and involuntary urination as well as negative effects on sexuality and sexual relationships.

"In Kenya there are urban settings where we are doing too many C-sections, yet in the rural areas we don’t have enough to save women’s lives,” says series lead author Marleen Temmerman, professor of obstetrics and gynaecology at Aga Khan University.

Less commonly cited reasons include convenience, perceived advantage of children being born on particular dates considered special or to have religious significance and negative experience with vaginal birth, in which expectant women were neglected or abused.

Mwende’s first pregnancy, eight years earlier, ended up in an emergency C-section following heavy bleeding. Her doctor had earlier diagnosed her with calcification of the placenta, which was affecting the supply of nutrients to her unborn baby, and recommended that she be induced to give birth naturally.

“Before the decision by my doctor to induce delivery, I realised that my baby was not moving regularly,” she recalls.

Even though her second pregnancy was uneventful and labour-quick, she feared that, given her earlier history and age (38), she could end up needing emergency surgery during the birth of her third child, so she figured it was better to plan for it. Her doctor left the decision to her.

Increasingly, more women are delivering through elective surgery, a trend that has alarmed medical experts.

Unjustified

The sharp increase in births by caesarean section around the world is unparalleled and unjustified, according to the Lancet series.

Caesarean section births doubled to 21 percent of all deliveries globally in the past 15 years, and they are increasing annually by four percent, reveals the three-part Lancet series.

Much of the increase is due to medically unnecessary surgeries that have not been accompanied by significant benefits for women and children.

On the contrary, there is growing evidence that having a medically unnecessary caesarean section may put the lives and well-being of women and their babies at risk.

It is estimated that 10-15 percent of births require C-sections for medical reasons. Higher rates are considered excessive by the World Health Organization.

In Kenya, the surgery is overused in some counties and underused in others, reveals a NationNewsplex review of maternal health data.

Caesarean rates in Kenya differ widely across counties, with up to a 23 percentage point difference between regions with the highest rate and those with the lowest.

About 6.2 million unnecessary caesarean sections were done annually worldwide.

When women who need a C-section for medical reasons cannot access the procedure, it leads to illnesses or death in mothers and their babies. Inversely, overuse can also cause harm or death.

When medically indicated, such as in the case of foetal distress, abnormal positioning and hypertensive diseases, the procedure saves the lives of women and babies.

Figures from the Statistical Review Towards the Mid-term Targets of the Kenya Health Sector Strategic Plan 2014-2018, indicate that one in four hospital births in Kiambu and Nairobi counties is by C-section. They were followed by Kirinyaga and Embu counties, where a fifth of deliveries were through surgery. Nyeri and Machakos counties, with 18 percent each, round off the top five.

Less than two percent of women who delivered in health facilities in Tana River, Wajir, Narok and Mandera underwent surgery.

Nationally, 13 percent of women who deliver in health facilities undergo a C-section, well within the recommended rate at the population level.

“In Kenya there are urban settings where we are doing too many C-sections, yet in the rural areas we don’t have enough to save women’s lives,” says series lead author Marleen Temmerman, professor of obstetrics and gynaecology at Aga Khan University.

Sometimes the influence of the baby’s father is the reason women opt for surgery. Prof Temmerman recalls a case where one of her patients insisted on giving birth through surgery. When she inquired further, she found out that it was her husband who wanted her to have the surgery.

In the media, births by C-section tend to be presented as controllable, convenient, fashionable, normal and modern. This influences some pregnant women to opt for the surgery.

Alongside health professionals’ personal financial benefit, other factors that drive the increase in caesarean section rates are financial pressure on hospitals, private health insurance, fear of lawsuits and the ability to manage physician and surgical work schedules.

A systematic review of data on 12.9 million women from the United States, Ireland and Australia found that privately insured women were more likely to choose caesarean section than women with public health insurance.

Alongside health professionals’ personal financial benefit, other factors that drive the increase in caesarean section rates are financial pressure on hospitals, private health insurance, fear of lawsuits and the ability to manage physician and surgical work schedules.

According to the series, contrary to scientific evidence, it is commonly believed that a C-section is a protective procedure. As a result, doctors are more likely to be sued for complications during vaginal deliveries than surgeries even if there is no evidence of error. This situation may result in health providers agreeing to do the procedure for professional protection rather than because it benefits mother and child.

If C-section deliveries can generate greater revenue than vaginal births, there are incentives to persuade women that it is the best delivery option. In faith-based organisatons, a normal delivery costs around Sh10,000 and a C-section costs about Sh30,000. However, all types of deliveries are free in public facilities due to a subsidy of Sh30,000 per procedure from the government. In the more costly private hospitals, normal delivery costs between Sh60,000 and Sh180,000 while a C-section goes for between Sh140,000 and Sh280,000.

In 2016 the National Hospital Insurance Fund announced that payouts for caesarean-section births accounted for almost 60 percent of the fund’s maternity costs.

In some hospitals, many C-sections occur during workdays, especially on Friday, suggesting that they are done at the convenience of doctors. In situations where obstetricians do private and public work, as in Kenya, scheduling elective surgery allows private work to be reconciled with public duties.

Effects

In some African countries, C-section deliveries are associated with very high maternal and newborn deaths and illnesses partly because of delays in performing the procedure, and inadequate facilities and skills. Such lapses could lead to anaesthetic and urological complications and excessive bleeding. There is also the possibility of contracting sepsis (infection) and organ injury.

They can also cause respiratory problems in newborns and lead to asthma and obesity in future.

The consequences for future pregnancies include an increase in spontaneous preterm birth, uterine rupture, abnormal placentation that may result in excessive bleeding and/ or need for hysterectomy.

In the US, higher C-section rates have been marginally associated with greater mortality.

While there is an overall rise in the application of the procedure, there are also wide discrepancies in C-section use across countries and regions. Of the 6.2 million unnecessary caesarean section deliveries each year worldwide, half are in Brazil and China.

In parts of Latin America like Brazil, the rate stands at 60 percent, 12 times the prevalence in Southern Africa, where the use of surgery is about five percent.

The series concludes that the wide variations reported between regions and within countries, and between women, show that caesarean use is not evidence-based.

But the series also recommends that efforts to reduce C-section must strongly respect women’s right to choose circumstances of birth.